subgaleal hemorrhage and skull fracture

[abeluchin]

Hi coleagues,

I recently came across to a baby in the newborn nursery with what appears clinically as a subgaleal hemorrage (SH). The infant was born at term 2800gram BW, required internal cephalic eversion x3, but no vaccum or forcepts were used. Initial exam was normal except for some scalp bruises. At ~ 8HOl, a significant scalp swelling was noted, concerning for SH( given the boggy sentation of palpation and that is covered all the occiput bilaterally), serial exam showed no significant progression of the swelling, and no extension into the neck. Head Circumsference initially was 33cm and did not increased on serial exams. Infant showed no ssx of shock, poor perfusion or CNS sings. Initial Hct was 55% and f/u Hct was 46% and remained stable with consecutive blood draws.Infant was feeding well in the NBN

Infant was doing well, but another member of the staff decided to obtain a CT scan that showed a small pin-pong parietal fracture with sorounded soft tissure edema and questionable SH

Based on this presentation:

1- Do you obtain brain image in every suspected SH?

2- Do you obtain brain image in clinically apparent SH in the abscent of neuro symptoms?

3- Do you ussually manage small SH in the newborn nursery until discharge home, if the baby remains clinically stable?

Thanks

 

[Urban Rosenqvist]

1 No

2 No

3 We dont have that many subgaleal hemorrages but a baby with typical symptoms and mildly decreasing Hct would probably have stayed in the nursery with repeated blood draws. A baby with signs of blood loss or rapidly decreasing Hct would have been admitted to our neonatal ward. 

[aridema]

1) no

2) no

And above all did you make anything for the fracture ? ... 

A CT scan exposed neonates to a higher risk of cancer during childhood... Be careful

Aridema

[Stefan Johansson]

1) no

2) no

3) As our NICU beds are relatively few we would manage asymtomatic infants with smaller subgaleal hematomas in the well baby nursery ("maternity ward"), but admit on liberal grounds, if any kinds of suspicious symtoms arise.

[Christian Heiring]

1) + 2) no

3) similar to what Stefan Johansson writes above

 

Christian

Rigshospitalet 

Copenhagen

[abeluchin]

Thanks to you all for your response. The baby was transfered for neuro eval and expectant management was carried out.

[Guest WoodWeans4]

1.no.

2no

 

we have recently developed a protocol for monitoring babies with risk factors for SGH but of course the last one in our NICU did not meet any of the risk criteria!

We have a low threshold for admitting to our NICU rather than monitoring clinically on the post natal ward

[DocForBabies]

Subgaleal hemorrhage is usually a medical emergency, babies with this need close monitoring:

 

http://www.cmaj.ca/content/164/10/1452.full.pdf

 

http://www.ncbi.nlm.nih.gov/pubmed/12762894

[HickOnACrick]

We have had 4 confirmed subgaleal hemorrhages (SH) in the past couple of months. We have long suspected that many caputs have an element of SH, but avoid CT imaging due to the radiation and that identifying a SH will not change our management in most cases, if the baby is otherwise doing well.

 

Of the 4 recent cases of SH, 2 have had more severe intracranial bleeding (intraventricular and subdural hemorrhages) and skull fractures - one of which was depressed. One of the cases was clearly in need of further head imaging on admission, due to the clinical picture, but the other was much more occult. 

 

This seems to be the crux of the problem - suspected occult subgaleal hemorrhage. Is imaging necessary to confirm?

 

Each of these confirmed SHs had one thing in common - a drop in the Hct by at least 20%. The more severe cases experienced the drop earlier than the occult, less severe, SHs (12 hrs vs 48 hrs). Of the 4 cases, none required fluid resuscitation for hemorrhagic shock. 

 

With respect to the original questions:

1- Do you obtain brain image in every suspected SH? Not routinely. 

2- Do you obtain brain image in clinically apparent SH in the abscent of neuro symptoms? I do now, especially if the Hct is dropping, or there is thrombocytopenia or coagulopathy.  Skull radiographs may be enough to elicit a depressed skull fracture, which has possible implications in management. 

3- Do you usually manage small SH in the newborn nursery until discharge home, if the baby remains clinically stable? Probably dependent on comfort level with your local nursery, but no, I would not feel comfortable if a known SH was in the nursery, unless the NICU had been consulted.